Does marijuana contribute to psychoticillness?
Cannabis abuse is not benign, especially in adolescents.
Joseph M. Rey, MD, PhD
Honorary professor, department of psychological medicine, University of Sydney, Australia Evidence grows that marijuana use can cause acute psychosis, bring forward in time a first schizophrenia episode, and worsen the prognosis of patients with psychotic disorders.
Roger, age 16, had been smoking marijuana on and off for about 2 years. His parents knew but believed this was a stage and not dangerous; they had tried marijuana in their youth without harm. Roger’s smoking had increased to several joints daily since he started a relationship with an older girl, who shared and encouraged his habit.
His parents became worried when Roger began making unusual comments, saying that food did not taste “right” and he thought someone was poisoning him. They brought Roger for psychiatric consultation at the recommendation of their family physician.
History and examination revealed that Roger had experienced vague persecutory ideas for several weeks but no systematized delusions or hallucinations. I told Roger and his parents he probably had a drug-induced psychosis and that symptoms would likely disappear without recurrence if he stopped using marijuana. At 2-weeks’ follow-up, he described no more psychotic experiences and said he now realized the danger for him of smoking marijuana. A review 1 month later showed Roger was doing well, and I discharged him after reinforcing the importance of abstinence. But his case didn’t end there.
Two years later, I received a request for information about Roger’s episode from an acute inpatient facility. Roger had been admitted after an incident at the local mall in which he screamed at people and accused bystanders of trying to harm him. Despite using marijuana only occasionally, his behavior had been deteriorating and was becoming increasingly bizarre. The attending psychiatrist believed Roger had schizophrenia.
Clinicians regularly deal with patients such as Roger who suffer from a psychotic disorder and use marijuana. This is hardly surprisingbecause marijuana is the most widely used illicit drug. In 2006, 5% of 12th graders in the United States reported using marijuana dailyduring the previous month, and 42% had tried it at least once.
Is psychotic patients’ use of marijuana a coincidence? Self-medication? Or could cannabis cause psychotic illness? This debate elicitsstrong views among community and professional groups. To help you provide up-to-date advice to patients and families, this review:
describes the growing body of evidence on the mental health consequences of marijuana use
seeks to help you detect and deal with the effects of marijuana use in clinical practice.
MARIJUANA AND PSYCHOSIS
Although the neurobiologic association is unclear (Box 1),
up to 15% of users report psychotic phenomena after consuming marijuana.
Naturalistic and experimental studies have confirmed that marijuana can induce short-lived psychotic experiences.In two parallel trials, 22 healthy individuals
and 13 stable, antipsychotic-treated schizophrenia patients
were given 2.5 mg and 5 mgintravenously of delta-9-tetrahydrocannabinol (delta-9-THC)—the primary psychoactive constituent of marijuana. Both groups developeddose-related, transient, schizophrenia-like symptoms and altered perceptions:
Healthy volunteers showed the full range of psychotic symptoms. One individual said, “I thought you were giving me THCthrough the blood pressure machine and the sheets.”
Schizophrenia patients tended to report increases in the symptoms of their specific conditions. Those with paranoidillnesses, for example, reported an escalation in persecutory ideas.Transient psychotic phenomena are not equivalent to a psychotic illness, however. To meet diagnostic criteria for a psychotic disorder,symptoms must be persistent and impair psychosocial functioning.
WHO IS AT RISK?